OPM Ethics Form 1Rev. 4-29-15

OPM Ethics Form 1Rev. 4-29-15

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Written or electronic certification to accompany a State contract with a value of $50,000 or more, pursuant to C.G.S. §§ 4-250 and 4-252(c); Governor M. Jodi Rell’s Executive Order No. 1, Para. 8 and C.G.S. §9-612(f)(2).

INSTRUCTIONS:

Complete all sections of the form. Attach additional pages, if necessary, to provide full disclosure about any lawful campaign contributions made to campaigns of candidates for statewide public office or the General Assembly, as described herein. Sign and date the form, under oath, in the presence of a Commissioner of the Superior Court or Notary Public. Submit the completed form to the awarding State agency at the time of initial contract execution and if there is a change in the information contained in the most recently filed certification, such person shall submit an updated certification either (i) not later than thirty (30) days after the effective date of such change or (ii) upon the submittal of any new bid or proposal for a contract, whichever is earlier.Such person shall also submit an accurate, updated certification not later than fourteen days after the twelve-month anniversary of the most recently filed certification or updated certification.

CHECK ONE:Initial Certification12 MonthAnniversary Update (Multi-year contracts only.)

Updated Certification because of change of information contained in the most recently filed certification or twelve-month anniversary update.

GIFT CERTIFICATION:

As used in this certification, the following terms have the meaning set forth below:

1)“Contract” means that contract between the State of Connecticut(and/or one or more of it agencies or instrumentalities)and the Contractor, attached hereto, or as otherwise described by the awarding State agency below;

2)If this is an Initial Certification, “Execution Date” means the date the Contract is fully executed by, and becomes effective between, the parties; if this is a twelve-month anniversaryupdate, “Execution Date” means the date this certification is signed by the Contractor;

3)“Contractor” means the person, firm or corporation named as the contactor below;

4)“Applicable Public Official or State Employee” means any public official or state employee described in C.G.S. §4-252(c)(1)(i) or (ii);

5)“Gift” has the same meaning given that term in C.G.S. § 4-250(1);

6)“Principals or Key Personnel” means and refers to those principals and key personnel of the Contractor, and its or their agents, as described in C.G.S. §§ 4-250(5) and 4-252(c)(1)(B) and (C).

I, the undersigned, am a Principal or Key Personnel of the person, firm or corporation authorized to execute thiscertification on behalf of the Contractor. I hereby certify that, no gifts were made by (A) such person, firm, corporation, (B) any principals and key personnel of the person firm or corporation who participate substantially in preparing bids, proposals or negotiating state contracts or (C) any agent of such, firm, corporation, or principals or key personnel who participates substantially in preparing bids, proposals or negotiating state contracts, to (i) any public official or state employee of the state agency or quasi-public agency soliciting bids or proposals for state contracts who participates substantially in the preparation of bid solicitations or request for proposals for state contracts or the negotiation or award of state contracts or (ii) any public official or state employee of any other state agency, who has supervisory or appointing authority over such state agency or quasi-public agency.

I further certify that noPrincipals or Key Personnelknow of any action by the Contractor to circumvent (or which would result in the circumvention of) the above certification regardingGifts by providing for any other Principals, Key Personnel, officials, or employees of the Contractor,or its or their agents,to make a Gift to any ApplicablePublic Official or StateEmployee. I further certify that the Contractor made the bid or proposal for theContract without fraud or collusion with any person.

CAMPAIGN CONTRIBUTION CERTIFICATION:

I further certify that, on or after January 1, 2011, neither the Contractor nor any of its principals, as defined in C.G.S. § 9-612(f)(1), has made any campaigncontributions to, or solicited any contributions on behalf of, any exploratory committee, candidate committee, political committee, or party committee established by, or supporting or authorized to support, any candidate for statewide public office, in violation of C.G.S. § 9-612(f)(2)(A). I further certify that alllawfulcampaigncontributionsthat have been madeon or after January 1, 2011by the Contractor orany of its principals, as defined in C.G.S. § 9-612(f)(1), to,or solicited on behalf of, any exploratory committee, candidate committee, political committee, or party committee established by, or supporting or authorized to support any candidates for statewide public office or the General Assembly, are listed below:

Lawful Campaign Contributions to Candidates for Statewide Public Office:

Contribution DateName of ContributorRecipientValueDescription

______

______

______

______

______

______

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Lawful Campaign Contributions to Candidates for the General Assembly:

Contribution DateName of ContributorRecipientValueDescription

______

______

______

______

______

______

______

Sworn as true to the best of my knowledge and belief, subject to the penalties of false statement.

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Printed Contractor NamePrinted Nameof Authorized Official

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Signature of Authorized Official

Subscribedand acknowledged before me this ______day of ______, 20___.

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Commissioner of the Superior Court (or Notary Public)

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My Commission Expires